Provider Demographics
NPI:1295821858
Name:WICHITA STATE UNIVERSITY
Entity Type:Organization
Organization Name:WICHITA STATE UNIVERSITY
Other - Org Name:WICHITA STATE UNIVERSITY SPEECH LANGUAGE HEARING CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVOST AND SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:VIZZINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-978-3010
Mailing Address - Street 1:1845 FAIRMOUNT ST
Mailing Address - Street 2:CAMPUS BOX 99
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0099
Mailing Address - Country:US
Mailing Address - Phone:316-978-3289
Mailing Address - Fax:316-978-7264
Practice Address - Street 1:5015 E 29TH STN
Practice Address - Street 2:DOOR T
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2110
Practice Address - Country:US
Practice Address - Phone:316-978-3289
Practice Address - Fax:316-978-7264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200004590AMedicaid
KS100345290CMedicaid